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Last Modified: 1/7/2018 Location: FL, PR, USVI Business: Part B

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Appeals forms

Providers, participating physicians, and other suppliers have the right to appeal claim decisions. Appeals must be submitted using the following forms:
More_arrow.gif"%> First level: Request for redetermination of a Part B claim
Florida pdf.gif"%>
Puerto Rico pdf.gif"%>
U.S. Virgin Islands pdf.gif"%>
More_arrow.gif"%> Second level: Reconsideration request form -- C2C Innovative Solutions Inc.
Florida pdf.gif"%>
Puerto Rico pdf.gif"%>
U.S. Virgin Islands pdf.gif"%>
More_arrow.gif"%> Third level: Hearing by an administrative law judge
More_arrow.gif"%> Fourth level: Medicare Appeals Council
More_arrow.gif"%> Overpayment forms

Minor error? Request a claim reopening

Did your claim have a clerical error or other minor discrepancy? Part B claims may be corrected outside of the appeals process.
More_arrow.gif"%> Correct your claim online through the SPOT -- SPOT offers registered users the time-saving advantage of not only viewing claim data online but also the option of correcting clerical errors in their eligible Part B claims quickly, easily, and securely -- online.
More_arrow.gif"%> Correct your claim using the interactive voice response (IVR) -- The IVR allows providers/customers to call in to request reopenings on certain claims
View the IVR reopening request help sheet pdf.gif"%> for assistance
More_arrow.gif"%> Correct your claim by writing in, using the first level of appeal (redetermination). Writing in allows you to supply additional information you feel is necessary to correct a claim.

Additional resources

More_arrow.gif"%> Understand when to file an appeal and the time limits for filing requests
First Coast Service Options (First Coast) strives to ensure that the information available on our provider website is accurate, detailed, and current. Therefore, this is a dynamic site and its content changes daily. It is best to access the site to ensure you have the most current information rather than printing articles or forms that may become obsolete without notice.
Part B